For Consumers

When your plan denies treatment or service for a behavioral health issue

  Important! If you or someone you know is experiencing a mental health crisis, call, text or chat 988, the 988 Suicide and Crisis Lifeline (988lifeline.org) for immediate help.

Appeal the denial

If your health insurance plan denies a mental health or substance use disorder service, you can appeal the denial. For help with writing an appeal, see our example for a mental health and substance abuse appeal letter.

  • You should use your grievance and appeals rights. 
  • Your insurance company is required to provide a written denial explaining why your service was denied.
  • The insurance company must make a decision within 30 days or sooner if your life or health is at risk.
  • If the insurance company denies your appeal, you have the right to seek an external review from an independent review organization (IRO).

How to request additional information from your insurer

If the denial explanation you received from your insurer is not sufficient, you or your provider can fill out the Mental Health and Substance Use Disorder Parity Disclosure Request form (www.dol.gov) (PDF, 180 KB, ). The form can help you obtain more detailed information from your insurer about:

  • General information about treatment limits, like your health plan’s preauthorization policies for both medical/surgical and mental health treatment. 
  • Specific information about why benefits were denied. For example, you can ask about the criteria for “failure to show medical necessity” that your health insurer may have used to deny your claim. 

After your insurer receives the completed form, they have 30 calendar days to respond. If you don’t receive a response within 30 days, you can file a complaint with our office.

When to file a complaint with our office

You can file a complaint with our office for any service or treatment issue, such as:

  • Accessing in-network providers
  • Benefit limits
  • Denial of services
  • Denial of prescription drug step therapy
  • Denial of telemedicine appointments